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Lessons learned from laparoscopic gastric banding for morbid obesity
The American Journal of Surgery 182 (2001) 10 –14
Laparoscopy
Lessons learned from laparoscopic gastric banding for morbid obesity Jeff W. Allen, M.D.a,*, Mark G. Coleman, M.B.Ch.B.b, George A. Fielding, M.B.B.S.c a
Department of Surgery, University of Louisville, Louisville, KY 40292, USA b Department of Surgery, Royal Brisbane Hospital, Brisbane, Australia c Wesley Hospital, Brisbane, Australia Manuscript received April 5, 2000; revised manuscript February 14, 2001
Abstract Background: Laparoscopic gastric banding is a minimally invasive bariatric operation that is increasing in popularity at many centers worldwide. Although this procedure is not yet approved in the United States, clinical trials are ongoing. Methods: We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity. The procedure was performed at the Wesley Obesity Clinic in Brisbane, Australia. Results: At follow-up, 51 of the 60 patients (85%) still had the laparoscopic gastric band in place. All of the patients had a lower body weight after undergoing the procedure. The average weight loss was 39 kg (range 2 to 98 kg), representing a loss of 65% of average excess body weight. Twenty-five of 51 patients (49%) regained some weight after their initial loss, but the average amount was only 5 kg. The remaining 26 patients have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. There was no operative mortality. Complications predominantly were caused by band slippage (21%), which has been nearly eliminated in recent practice (1 slip in the last 225 cases). Subsequent modifications in the technique to prevent band slippage included placing the band near the level of the esophagus, with minimal disruption of the posterior gastric attachments and diligent suturing of the band in place. Conclusions: We conclude that the laparoscopic gastric band is effective in short- and long-term weight loss. The high rate of reoperation for repositioning has been avoided in current practice. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopic gastric banding; Morbid obesity; Bariatric surgery; Weight loss
According to the National Health and Nutrition Examination Study, among American women the mean body mass index (BMI) from 1960 through 1962 was 24.4 kg/m2 and increased to 26.1 kg/m2 from 1988 through 1991. Among American men, the BMI increased from 25.0 kg/m2 to 26.3 kg/m2 during the same period [1]. Even though there is no consensus on the medical definition of morbid obesity, it is commonly referred to as a BMI of greater than 40 kg/m2. As such, it is an increasingly common problem in the United States. Dietary and behavioral modifications have had limited long-term success in the best of series, and surgery remains the only effective treatment for medically severe obesity [2]. Interest in surgery to correct this disorder has waxed and waned over the past 5 decades, since its inception with intestinal bypass in 1954. A minimally invasive approach, laparoscopic gastric band placement has shown great promise in early follow-up
* Corresponding author. Tel.: ⫹1-502-852-5675; fax ⫹1-502-8528915.
[3] and should gain wide acceptance if long-term weight loss accompanies the excellent initial results. During this procedure, a silicone adjustable banding system with an inflatable inner surface (BioEnterics Corporation, Santa Barbara, California) is placed around the stomach near the gastroesophageal junction (Fig. 1). A subcutaneous port is placed to permit inflation and deflation of the band. After inflation, a small gastric pouch (approximately 10 mL) is created that produces a feeling of satiety after only a small meal. We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity at the Wesley Obesity Clinic in Brisbane, Australia.
Methods A total of 600 laparoscopic gastric band procedures have been performed to date for morbid obesity at the Wesley Obesity Clinic in Brisbane, Australia. There have been no
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 4 8 - 1
J.W. Allen et al. / The American Journal of Surgery 182 (2001) 10 –14
11
Fig. 3. The laparoscopic gastric band is sutured in at least three places with nonabsorbable material. Fig. 1. The laparoscopic gastric band is placed near gastroesophageal junction.
deaths or clinical evidence of pulmonary emboli in the entire series. Of these 600 patients, we studied 63 consecutive patients who underwent laparoscopic gastric band surgery between February 5, 1996, and August 12, 1996, and whose clinical data were followed up for 3 years after the procedure (Fig. 2). Sixty patients (95%) were available for follow-up; the other 3 were lost to follow-up. All of the gastric band procedures were completed laparoscopically. Contact through regular office visits was maintained during
follow-up. The follow-up data collected included weight gains and losses, removal of the gastric band, and complications. All of the patients who presented to the clinic seeking weight-reduction surgery were initially screened for any medical causes of the obesity, including hypothyroidism. In addition, preoperative medical and psychiatric clearance was obtained. The patients underwent consultation with a dietician to elucidate eating disorders and expected postoperative diet. The two surgical options for weight reduction offered to each patients included laparoscopic gastric banding or open biliopancreatic bypass as described by Scopinaro et al [4]. Laparoscopic gastric banding instead of open biliopancreatic bypass was primarily selected by patients with the financial means to pay for the procedure themselves, as the Australian health system covered open bypass and not the laparoscopic gastric band procedure. The technique of laparoscopic gastric band placement involved obtaining open pneumoperitoneum to 15 mm Hg, placement of four working ports, and initial incision of the pars flacida (gastrohepatic ligament). The right crus of the diaphragm was identified and circumferential control of the cardia of the stomach obtained. The band was then placed around the cardia of the stomach and sutured in place with gastric to gastric sutures (Fig. 3).
Results Fig. 2. Outcome of patients undergoing the laparoscopic gastric band procedure.
Of the 60 patients studied, 55 were women (92%) and 5 were men (8%). The average age of the patient was 41 years
12
J.W. Allen et al. / The American Journal of Surgery 182 (2001) 10 –14
Table 1 Weight gains and losses in 51 patients with laparoscopic gastric bands in place at follow-up
Average body weight (range) Body mass index (range) Average excess weight Excess weight lost
Preoperative measurements
At follow-up Lowest measurements
Most recent measurements
130 kg (88–230 kg) 46 kg/m2 (34–63 kg/m2) 60 kg
86 kg (57–120 kg) 31 kg/m2 (25–46 kg/m2) 15 kg (75%)
91 kg (59–120 kg) 32 kg/m2 (25–47 kg/m2) 24 kg (65%)
(range 31 to 60). The average body weight before the procedure was 127 kg (range 86 to 230 kg). The average preoperative BMI was 46 kg/m2 (range 34 to 65 kg/m2). Nine patients had their gastric band removed during the follow-up period. Reasons for removal included patient’s preference (n ⫽ 3), failure to lose weight (n ⫽ 1), gastric volvulus (n ⫽ 3), or port migration (n ⫽ 2). The remaining 51 patients (46 women, 5 men) were an average age of 41 years (range 31 to 60) at the time of operation. Their average body weight before the procedure was 130 kg (range 88 to 230 kg). The average preoperative BMI was 46 kg/m2 (range 34 to 63 kg/m2). The average excess weight, as determined by preoperative weight minus ideal body weight (IBW), was 60 kg (range 22 to 138 kg). All of the 51 patients who had the gastric bands in place at follow-up (range 38 to 44 months; mean 40) weighed below their initial preoperative measurements. The range of weight loss was 2 to 98 kg (mean weight loss 39 kg). Average body weight at follow-up in this group was 91 kg (range 59 to 120 kg), corresponding with an average BMI of 32 kg/m2 (range 25 to 47 kg/m2). There was a loss of 65% of excess body weight (range 3% to 109%) on average (Table 1). After the laparoscopic gastric band procedure, the average minimum weight was 86 kg (range 57 to 120 kg). This measurement occurred an average of 130 weeks after the operation (range 25 to 182 weeks). The mean minimum weight corresponded with a BMI of 31 kg/m2 and an excess weight loss of 75%. Twenty-six of the 51 patients (51%) have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. Twenty-five patients (49%) experienced modest weight gain. Of those, the median weight regained was 7 kg. The average weight at follow-up was 5 kg above their lowest recorded body weight (range of weight regained, 0 to 53 kg). In 12 patients (20%), band repositioning was necessary. This occurred an average of 10 months postoperatively (range 3 to 21). There were two infections at the inflation port site (3%). Two inflation port migrations (3%) required surgical correction. There were no erosions of the band. Nine patients (15%) had their gastric bands removed;
and 6 of those subsequently underwent biliopancreatic bypass as described by Scopinaro et al [5]. Those patients who chose to have their gastric bands removed did not have an appreciable weight loss. Those who had a “salvage” Scopinaro procedure lost an average of 28 kg. The bands in these 6 patients were removed an average of 31 months postoperatively (range 27 to 37). Reasons for removal of the gastric bands in patients who did not undergo biliopancreatic bypass were dysphagia without evidence of band slippage (n ⫽ 1), unhappiness (n ⫽ 1), and attainment of weight loss/patient choice (n ⫽ 1). The bands were removed at 15, 24, and 29 months after surgery, respectively (Fig. 2).
Comments There are many medical hazards of obesity, including increased risk for insulin resistance, hypertension, hyperlipidemia, cardiovascular disease, noninsulin-dependent diabetes mellitus, cholelithiasis, cholecystitis, respiratory dysfunction, and some forms of cancer [6]. Patients more than 20% overweight have twice the prevalence of hypertension than persons who are normal weight [7]. As reported by Manson et al [8], a higher BMI in women is associated with a greater risk of coronary artery disease. The relative risk for nonfatal myocardial infarction and fatal coronary heart disease is 1.3 for a BMI of 23 to 25 kg/m2, 1.8 for a BMI of 25 to 29 kg/m2, and 3.3 for a BMI of greater than 29 kg/m2 [8]. All of our patients had a preoperative BMI of greater than 29 kg/m2, corresponding with a 3.3 relative risk for nonfatal myocardial infarction and fatal coronary heart disease in women, as noted by Manson et al [8]. Although the average BMI in our series was 32.2 kg/m2, which would correspond with the maximum relative risk of 3.3, there were 15 women in the group who had BMIs less than 29 kg/m2, with a relative risk of 1.8 or less. For men who are more than 40% overweight compared with men of average weight, the cancer mortality ratio is 1.33; for women, it is 1.55 [9]. All but 2 patients in our original group were more than 40% overweight at the time of laparoscopic gastric band placement. Based on the current weight of our patients with gastric bands still in place, 37 (73%) were less than 40% overweight. Surgery remains the best treatment for long-term management of morbid obesity. Available since 1991, the laparoscopic gastric band procedure is approved for use in Europe, Asia, and Australia [10]. Numerous short-term studies have found it to be safe and effective for weight loss [10 –12]. However, studies with longer follow-up periods are just beginning to surface. We found the laparoscopic gastric band effective for short- and long-term weight loss. Weight gain after gastric banding has not been a substantial problem. More than half of our patients are at their lowest body weight after gastric banding or continue to lose
J.W. Allen et al. / The American Journal of Surgery 182 (2001) 10 –14
weight. Of those who regained weight, the gains have been modest (average 5 kg). The laparoscopic gastric band procedure has many appealing features for the bariatric surgeon. It is a minimally invasive procedure that is reversible. Complications are generally mild, although band erosion is potentially a serious problem. Common complications unique to this procedure are pouch dilatation and band migration. Both manifest as symptomatic gastroesophageal reflux, nausea, vomiting, dysphagia, and total food intolerance. Initial management may include hospital admission, nasogastric decompression, and gastric band deflation. However, both conditions require operation and repositioning of the band when conservative measures fail to improve symptoms. Twelve of the original 60 patients (20%) underwent band repositioning in the 3 years after the procedure. As reported by Niville et al [13], this can be accomplished safely through the laparoscopic approach by opening the band, disconnecting it from the inflation port, and repositioning more cephalad on the stomach. We have had the same experience at our center, with 9 of the 12 (75%) gastric bands successfully repositioned laparoscopically. There was no significant morbidity associated with repositioning of the band. The severity and rate of complications of laparoscopic gastric band surgery compare favorably with other forms of bariatric surgery. Although rates vary with each center and the experience of the surgeon, the incidence of staple line disruption was reported to be 22% for vertical banded gastroplasty with Roux-en-Y gastric bypass [14]. Based on Kaplan-Meier analyses, 56% of patients will require revisional surgery within 12 years after a vertical banded gastroplasty without Roux-en-Y gastric bypass [15]. Complications after a vertical banded gastroplasty are often serious and include gastric perforation (2%), enterocutaneous fistula (1%), severe esophagitis (12%), and intestinal obstruction (2%) [16]. Gastric bypass is complicated by death (1.5%), wound seromas or infections (17.5%), splenic tears (2.5%), and subphrenic abscess (2.5%). Patients undergoing gastric bypass required early reoperation 2.8% of the time in one series of more than 600 patients [17]. Late complications include vitamin B12 deficiency (40%), anemia (39%), incisional hernia (24%), staple-line failure (15%), and bile reflux (9%) [17]. Our band migration and pouch dilation rates requiring reoperation have prompted certain modifications and improvements in the placement technique. As previously reported, we modified the technique after a high rate of slips were noted [18]. At present, the band is affixed in at least three places with nonabsorbable sutures and with specific emphasis on the posterior gastric wall (Fig. 3). The band is placed close to the esophagus, allowing for a tiny pouch (10 mL) with minimal posterior disruption of gastric attachments. Dissection is through the pars flaccida, away from the stomach. Since making this modification, no slips have occurred in 125 consecutive gastric bands that were placed within the past year.
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Other improvements in instrumentation as well as familiarity of the operating staff with the procedure have sped up the operation. The total anesthesia time was 71 minutes (range 30 to 240) for the last 125 procedures. We conclude that the 3-year results of laparoscopic gastric band placement are quite good. Excellent weight loss is obtained, and a minimal amount of weight is regained. The laparoscopic gastric band procedure is safe, with no deaths or life-threatening complications in our series. However, there is a steep learning curve for the procedure, and advanced laparoscopic skills are required. Modifying our placement technique has led to sharply reduced problems with band slippage. When slips do occur, they often can be safely repositioned laparoscopically, but require advanced laparoscopic skills and experience. Patients undergoing bariatric operations need frequent, personal follow-up by the surgeon. We believe this procedure, as based on our 3-year follow-up data, is a valid alternative to open bariatric procedures. Laparoscopic gastric band placement offers the attraction of a laparoscopic procedure and the attendant low perioperative risks. A dedicated bariatric center staffed with a full array of professional laparoscopic specialists is best suited to care for patients undergoing laparoscopic gastric band surgery.
References [1] Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults: the National Health and Nutrition Examination Surveys, 1960 to 1991. JAMA 1994;272:205– 11. [2] Brolin RE. Update: NIH consensus conference: gastrointestinal surgery for morbid obesity. Nutrition 1996;12:403– 4. [3] Lecomte P, Marmuse JP. Treatment of morbid obesity by adjustable silicone gastric banding: a new surgical technique of gastroplasty for obesity. J Chir (Paris) 1996;133:226 – 8. [4] Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg 1998;22:936 – 46. [5] Scopinaro N, Gianetta E, Civalleri D, et al. Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg 1979;66:618 –20. [6] Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med 1993; 119:655– 60. [7] Havlik RJ, Hubert HB, Fabsitz RR, Feinlab M. Weight and hypertension. Ann Intern Med 1983;98:855–9. [8] Manson JE, Colditz GA, Stampfer MJ, et al. A prospective study of obesity and risk of coronary heart disease in women. N Engl J Med 1990;322:882–9. [9] Garfinkle L. Overweight and cancer. Ann Intern Med 1985;103: 1034 – 6. [10] Belachew M, Legrand M, Vincent V, et al. Laparoscopic adjustable gastric banding. World J Surg 1998;22:955– 63. [11] O’Brien PE, Brown WA, Smith PJ, et al. Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg 1999;86:113–18. [12] Miller K, Hell E. Laparoscopic adjustable gastric banding: a prospective 4-year follow-up study. Obes Surg 1999;9:183–7. [13] Niville E, Dams A, Anne T. Laparoscopic repositioning of an adjustable silicone gastric band for pouch dilatation and stoma obstruction. Surg Endosc 1999;13:65–7.
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[14] Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg 1996;171: 74 –9. [15] van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg. 1998;8:21– 8. [16] Papakonstantinou A, Alfaras P, Komessidou V, Hadjiyannakis E.
Gastrointestinal complications after vertical banded gastroplasty. Obes Surg 1998;8:215–17. [17] Pories WP, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339 –52. [18] Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity: surgical outcome in 335 cases. Surg Endosc 1999;13:550 – 4.
Laparoscopy
Lessons learned from laparoscopic gastric banding for morbid obesity Jeff W. Allen, M.D.a,*, Mark G. Coleman, M.B.Ch.B.b, George A. Fielding, M.B.B.S.c a
Department of Surgery, University of Louisville, Louisville, KY 40292, USA b Department of Surgery, Royal Brisbane Hospital, Brisbane, Australia c Wesley Hospital, Brisbane, Australia Manuscript received April 5, 2000; revised manuscript February 14, 2001
Abstract Background: Laparoscopic gastric banding is a minimally invasive bariatric operation that is increasing in popularity at many centers worldwide. Although this procedure is not yet approved in the United States, clinical trials are ongoing. Methods: We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity. The procedure was performed at the Wesley Obesity Clinic in Brisbane, Australia. Results: At follow-up, 51 of the 60 patients (85%) still had the laparoscopic gastric band in place. All of the patients had a lower body weight after undergoing the procedure. The average weight loss was 39 kg (range 2 to 98 kg), representing a loss of 65% of average excess body weight. Twenty-five of 51 patients (49%) regained some weight after their initial loss, but the average amount was only 5 kg. The remaining 26 patients have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. There was no operative mortality. Complications predominantly were caused by band slippage (21%), which has been nearly eliminated in recent practice (1 slip in the last 225 cases). Subsequent modifications in the technique to prevent band slippage included placing the band near the level of the esophagus, with minimal disruption of the posterior gastric attachments and diligent suturing of the band in place. Conclusions: We conclude that the laparoscopic gastric band is effective in short- and long-term weight loss. The high rate of reoperation for repositioning has been avoided in current practice. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopic gastric banding; Morbid obesity; Bariatric surgery; Weight loss
According to the National Health and Nutrition Examination Study, among American women the mean body mass index (BMI) from 1960 through 1962 was 24.4 kg/m2 and increased to 26.1 kg/m2 from 1988 through 1991. Among American men, the BMI increased from 25.0 kg/m2 to 26.3 kg/m2 during the same period [1]. Even though there is no consensus on the medical definition of morbid obesity, it is commonly referred to as a BMI of greater than 40 kg/m2. As such, it is an increasingly common problem in the United States. Dietary and behavioral modifications have had limited long-term success in the best of series, and surgery remains the only effective treatment for medically severe obesity [2]. Interest in surgery to correct this disorder has waxed and waned over the past 5 decades, since its inception with intestinal bypass in 1954. A minimally invasive approach, laparoscopic gastric band placement has shown great promise in early follow-up
* Corresponding author. Tel.: ⫹1-502-852-5675; fax ⫹1-502-8528915.
[3] and should gain wide acceptance if long-term weight loss accompanies the excellent initial results. During this procedure, a silicone adjustable banding system with an inflatable inner surface (BioEnterics Corporation, Santa Barbara, California) is placed around the stomach near the gastroesophageal junction (Fig. 1). A subcutaneous port is placed to permit inflation and deflation of the band. After inflation, a small gastric pouch (approximately 10 mL) is created that produces a feeling of satiety after only a small meal. We report our results of a 3-year follow-up on 60 patients who underwent the laparoscopic gastric band procedure for the treatment of morbid obesity at the Wesley Obesity Clinic in Brisbane, Australia.
Methods A total of 600 laparoscopic gastric band procedures have been performed to date for morbid obesity at the Wesley Obesity Clinic in Brisbane, Australia. There have been no
0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S 0 0 0 2 - 9 6 1 0 ( 0 1 ) 0 0 6 4 8 - 1
J.W. Allen et al. / The American Journal of Surgery 182 (2001) 10 –14
11
Fig. 3. The laparoscopic gastric band is sutured in at least three places with nonabsorbable material. Fig. 1. The laparoscopic gastric band is placed near gastroesophageal junction.
deaths or clinical evidence of pulmonary emboli in the entire series. Of these 600 patients, we studied 63 consecutive patients who underwent laparoscopic gastric band surgery between February 5, 1996, and August 12, 1996, and whose clinical data were followed up for 3 years after the procedure (Fig. 2). Sixty patients (95%) were available for follow-up; the other 3 were lost to follow-up. All of the gastric band procedures were completed laparoscopically. Contact through regular office visits was maintained during
follow-up. The follow-up data collected included weight gains and losses, removal of the gastric band, and complications. All of the patients who presented to the clinic seeking weight-reduction surgery were initially screened for any medical causes of the obesity, including hypothyroidism. In addition, preoperative medical and psychiatric clearance was obtained. The patients underwent consultation with a dietician to elucidate eating disorders and expected postoperative diet. The two surgical options for weight reduction offered to each patients included laparoscopic gastric banding or open biliopancreatic bypass as described by Scopinaro et al [4]. Laparoscopic gastric banding instead of open biliopancreatic bypass was primarily selected by patients with the financial means to pay for the procedure themselves, as the Australian health system covered open bypass and not the laparoscopic gastric band procedure. The technique of laparoscopic gastric band placement involved obtaining open pneumoperitoneum to 15 mm Hg, placement of four working ports, and initial incision of the pars flacida (gastrohepatic ligament). The right crus of the diaphragm was identified and circumferential control of the cardia of the stomach obtained. The band was then placed around the cardia of the stomach and sutured in place with gastric to gastric sutures (Fig. 3).
Results Fig. 2. Outcome of patients undergoing the laparoscopic gastric band procedure.
Of the 60 patients studied, 55 were women (92%) and 5 were men (8%). The average age of the patient was 41 years
12
J.W. Allen et al. / The American Journal of Surgery 182 (2001) 10 –14
Table 1 Weight gains and losses in 51 patients with laparoscopic gastric bands in place at follow-up
Average body weight (range) Body mass index (range) Average excess weight Excess weight lost
Preoperative measurements
At follow-up Lowest measurements
Most recent measurements
130 kg (88–230 kg) 46 kg/m2 (34–63 kg/m2) 60 kg
86 kg (57–120 kg) 31 kg/m2 (25–46 kg/m2) 15 kg (75%)
91 kg (59–120 kg) 32 kg/m2 (25–47 kg/m2) 24 kg (65%)
(range 31 to 60). The average body weight before the procedure was 127 kg (range 86 to 230 kg). The average preoperative BMI was 46 kg/m2 (range 34 to 65 kg/m2). Nine patients had their gastric band removed during the follow-up period. Reasons for removal included patient’s preference (n ⫽ 3), failure to lose weight (n ⫽ 1), gastric volvulus (n ⫽ 3), or port migration (n ⫽ 2). The remaining 51 patients (46 women, 5 men) were an average age of 41 years (range 31 to 60) at the time of operation. Their average body weight before the procedure was 130 kg (range 88 to 230 kg). The average preoperative BMI was 46 kg/m2 (range 34 to 63 kg/m2). The average excess weight, as determined by preoperative weight minus ideal body weight (IBW), was 60 kg (range 22 to 138 kg). All of the 51 patients who had the gastric bands in place at follow-up (range 38 to 44 months; mean 40) weighed below their initial preoperative measurements. The range of weight loss was 2 to 98 kg (mean weight loss 39 kg). Average body weight at follow-up in this group was 91 kg (range 59 to 120 kg), corresponding with an average BMI of 32 kg/m2 (range 25 to 47 kg/m2). There was a loss of 65% of excess body weight (range 3% to 109%) on average (Table 1). After the laparoscopic gastric band procedure, the average minimum weight was 86 kg (range 57 to 120 kg). This measurement occurred an average of 130 weeks after the operation (range 25 to 182 weeks). The mean minimum weight corresponded with a BMI of 31 kg/m2 and an excess weight loss of 75%. Twenty-six of the 51 patients (51%) have remained at their lowest body weight recorded after the procedure or are continuing to lose weight. Twenty-five patients (49%) experienced modest weight gain. Of those, the median weight regained was 7 kg. The average weight at follow-up was 5 kg above their lowest recorded body weight (range of weight regained, 0 to 53 kg). In 12 patients (20%), band repositioning was necessary. This occurred an average of 10 months postoperatively (range 3 to 21). There were two infections at the inflation port site (3%). Two inflation port migrations (3%) required surgical correction. There were no erosions of the band. Nine patients (15%) had their gastric bands removed;
and 6 of those subsequently underwent biliopancreatic bypass as described by Scopinaro et al [5]. Those patients who chose to have their gastric bands removed did not have an appreciable weight loss. Those who had a “salvage” Scopinaro procedure lost an average of 28 kg. The bands in these 6 patients were removed an average of 31 months postoperatively (range 27 to 37). Reasons for removal of the gastric bands in patients who did not undergo biliopancreatic bypass were dysphagia without evidence of band slippage (n ⫽ 1), unhappiness (n ⫽ 1), and attainment of weight loss/patient choice (n ⫽ 1). The bands were removed at 15, 24, and 29 months after surgery, respectively (Fig. 2).
Comments There are many medical hazards of obesity, including increased risk for insulin resistance, hypertension, hyperlipidemia, cardiovascular disease, noninsulin-dependent diabetes mellitus, cholelithiasis, cholecystitis, respiratory dysfunction, and some forms of cancer [6]. Patients more than 20% overweight have twice the prevalence of hypertension than persons who are normal weight [7]. As reported by Manson et al [8], a higher BMI in women is associated with a greater risk of coronary artery disease. The relative risk for nonfatal myocardial infarction and fatal coronary heart disease is 1.3 for a BMI of 23 to 25 kg/m2, 1.8 for a BMI of 25 to 29 kg/m2, and 3.3 for a BMI of greater than 29 kg/m2 [8]. All of our patients had a preoperative BMI of greater than 29 kg/m2, corresponding with a 3.3 relative risk for nonfatal myocardial infarction and fatal coronary heart disease in women, as noted by Manson et al [8]. Although the average BMI in our series was 32.2 kg/m2, which would correspond with the maximum relative risk of 3.3, there were 15 women in the group who had BMIs less than 29 kg/m2, with a relative risk of 1.8 or less. For men who are more than 40% overweight compared with men of average weight, the cancer mortality ratio is 1.33; for women, it is 1.55 [9]. All but 2 patients in our original group were more than 40% overweight at the time of laparoscopic gastric band placement. Based on the current weight of our patients with gastric bands still in place, 37 (73%) were less than 40% overweight. Surgery remains the best treatment for long-term management of morbid obesity. Available since 1991, the laparoscopic gastric band procedure is approved for use in Europe, Asia, and Australia [10]. Numerous short-term studies have found it to be safe and effective for weight loss [10 –12]. However, studies with longer follow-up periods are just beginning to surface. We found the laparoscopic gastric band effective for short- and long-term weight loss. Weight gain after gastric banding has not been a substantial problem. More than half of our patients are at their lowest body weight after gastric banding or continue to lose
J.W. Allen et al. / The American Journal of Surgery 182 (2001) 10 –14
weight. Of those who regained weight, the gains have been modest (average 5 kg). The laparoscopic gastric band procedure has many appealing features for the bariatric surgeon. It is a minimally invasive procedure that is reversible. Complications are generally mild, although band erosion is potentially a serious problem. Common complications unique to this procedure are pouch dilatation and band migration. Both manifest as symptomatic gastroesophageal reflux, nausea, vomiting, dysphagia, and total food intolerance. Initial management may include hospital admission, nasogastric decompression, and gastric band deflation. However, both conditions require operation and repositioning of the band when conservative measures fail to improve symptoms. Twelve of the original 60 patients (20%) underwent band repositioning in the 3 years after the procedure. As reported by Niville et al [13], this can be accomplished safely through the laparoscopic approach by opening the band, disconnecting it from the inflation port, and repositioning more cephalad on the stomach. We have had the same experience at our center, with 9 of the 12 (75%) gastric bands successfully repositioned laparoscopically. There was no significant morbidity associated with repositioning of the band. The severity and rate of complications of laparoscopic gastric band surgery compare favorably with other forms of bariatric surgery. Although rates vary with each center and the experience of the surgeon, the incidence of staple line disruption was reported to be 22% for vertical banded gastroplasty with Roux-en-Y gastric bypass [14]. Based on Kaplan-Meier analyses, 56% of patients will require revisional surgery within 12 years after a vertical banded gastroplasty without Roux-en-Y gastric bypass [15]. Complications after a vertical banded gastroplasty are often serious and include gastric perforation (2%), enterocutaneous fistula (1%), severe esophagitis (12%), and intestinal obstruction (2%) [16]. Gastric bypass is complicated by death (1.5%), wound seromas or infections (17.5%), splenic tears (2.5%), and subphrenic abscess (2.5%). Patients undergoing gastric bypass required early reoperation 2.8% of the time in one series of more than 600 patients [17]. Late complications include vitamin B12 deficiency (40%), anemia (39%), incisional hernia (24%), staple-line failure (15%), and bile reflux (9%) [17]. Our band migration and pouch dilation rates requiring reoperation have prompted certain modifications and improvements in the placement technique. As previously reported, we modified the technique after a high rate of slips were noted [18]. At present, the band is affixed in at least three places with nonabsorbable sutures and with specific emphasis on the posterior gastric wall (Fig. 3). The band is placed close to the esophagus, allowing for a tiny pouch (10 mL) with minimal posterior disruption of gastric attachments. Dissection is through the pars flaccida, away from the stomach. Since making this modification, no slips have occurred in 125 consecutive gastric bands that were placed within the past year.
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Other improvements in instrumentation as well as familiarity of the operating staff with the procedure have sped up the operation. The total anesthesia time was 71 minutes (range 30 to 240) for the last 125 procedures. We conclude that the 3-year results of laparoscopic gastric band placement are quite good. Excellent weight loss is obtained, and a minimal amount of weight is regained. The laparoscopic gastric band procedure is safe, with no deaths or life-threatening complications in our series. However, there is a steep learning curve for the procedure, and advanced laparoscopic skills are required. Modifying our placement technique has led to sharply reduced problems with band slippage. When slips do occur, they often can be safely repositioned laparoscopically, but require advanced laparoscopic skills and experience. Patients undergoing bariatric operations need frequent, personal follow-up by the surgeon. We believe this procedure, as based on our 3-year follow-up data, is a valid alternative to open bariatric procedures. Laparoscopic gastric band placement offers the attraction of a laparoscopic procedure and the attendant low perioperative risks. A dedicated bariatric center staffed with a full array of professional laparoscopic specialists is best suited to care for patients undergoing laparoscopic gastric band surgery.
References [1] Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. Increasing prevalence of overweight among US adults: the National Health and Nutrition Examination Surveys, 1960 to 1991. JAMA 1994;272:205– 11. [2] Brolin RE. Update: NIH consensus conference: gastrointestinal surgery for morbid obesity. Nutrition 1996;12:403– 4. [3] Lecomte P, Marmuse JP. Treatment of morbid obesity by adjustable silicone gastric banding: a new surgical technique of gastroplasty for obesity. J Chir (Paris) 1996;133:226 – 8. [4] Scopinaro N, Adami GF, Marinari GM, et al. Biliopancreatic diversion. World J Surg 1998;22:936 – 46. [5] Scopinaro N, Gianetta E, Civalleri D, et al. Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg 1979;66:618 –20. [6] Pi-Sunyer FX. Medical hazards of obesity. Ann Intern Med 1993; 119:655– 60. [7] Havlik RJ, Hubert HB, Fabsitz RR, Feinlab M. Weight and hypertension. Ann Intern Med 1983;98:855–9. [8] Manson JE, Colditz GA, Stampfer MJ, et al. A prospective study of obesity and risk of coronary heart disease in women. N Engl J Med 1990;322:882–9. [9] Garfinkle L. Overweight and cancer. Ann Intern Med 1985;103: 1034 – 6. [10] Belachew M, Legrand M, Vincent V, et al. Laparoscopic adjustable gastric banding. World J Surg 1998;22:955– 63. [11] O’Brien PE, Brown WA, Smith PJ, et al. Prospective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg 1999;86:113–18. [12] Miller K, Hell E. Laparoscopic adjustable gastric banding: a prospective 4-year follow-up study. Obes Surg 1999;9:183–7. [13] Niville E, Dams A, Anne T. Laparoscopic repositioning of an adjustable silicone gastric band for pouch dilatation and stoma obstruction. Surg Endosc 1999;13:65–7.
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[14] Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass? Am J Surg 1996;171: 74 –9. [15] van Gemert WG, van Wersch MM, Greve JW, Soeters PB. Revisional surgery after failed vertical banded gastroplasty: restoration of vertical banded gastroplasty or conversion to gastric bypass. Obes Surg. 1998;8:21– 8. [16] Papakonstantinou A, Alfaras P, Komessidou V, Hadjiyannakis E.
Gastrointestinal complications after vertical banded gastroplasty. Obes Surg 1998;8:215–17. [17] Pories WP, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339 –52. [18] Fielding GA, Rhodes M, Nathanson LK. Laparoscopic gastric banding for morbid obesity: surgical outcome in 335 cases. Surg Endosc 1999;13:550 – 4.